NCLEX Exam 2 Study Guide graded A
NCLEX Exam 2
Cardiac
A client admitted to the hospital with chest pain and a history of type 2 diabetes
mellitus is scheduled for cardiac catheterization. Which medication would need to be
withheld for 24 hours before the procedure and for 48 hours after the procedure?
Metformin
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20
mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous
fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results
indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum
creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the
nurse would anticipate that the client is at risk for which problem?
Acute Kidney Injury
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS
complexes are regular. The PR interval is 0.16 seconds, and QRS complexes
measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action
should the nurse take?
Continue to monitor
A client is wearing a continuous cardiac monitor, which begins to sound its
alarm. The nurse sees no electrocardiographic complexes on the screen. Which
is the priority nursing action? Check the client's status and lead placement.
The nurse is evaluating a client's response to cardioversion. Which assessment
would be the priority?
Status of airway
The nurse is caring for a client who has just had implantation of an
automatic internal cardioverter-defibrillator. The nurse should assess
which item based on priority?
Activation status of the device, heart rate cutoff, and number of shocks it is programmed
to deliver
A client's electrocardiogram strip shows atrial and ventricular rates of 110
beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08
seconds, and the PP and RR intervals are regular. How should the nurse correctly
interpret this rhythm?
Sinus tachycardia
The nurse is assessing the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. How should the nurse correctly interpret
the client's neurovascular status?
The neurovascular status is normal because of increased blood flow through the leg.
, NCLEX Exam 2 Study Guide graded A
The nurse is evaluating the condition of a client after pericardiocentesis
performed to treat cardiac tamponade. Which observation would indicate that
the procedure was effective? A rise in blood pressure
, NCLEX Exam 2 Study Guide graded A
A client with variant angina is scheduled to receive an oral calcium channel blocker
twice daily. Which statement by the client indicates the need for further teaching?
"My spouse told me that since I have developed this problem, we are going to stop
walking in the mall every morning."
The nurse is monitoring a client with acute pericarditis for signs of cardiac
tamponade. Which assessment finding indicates the presence of this complication?
Muffled or distant heart sounds
The home care nurse is providing instructions to a client with an arterial ischemic leg
ulcer about home care management and self-care management. Which statement,
if made by the client, indicates a need for further instruction?
"I need to be sure that I elevate my leg above the level of my heart for at least an hour
every day."
The nurse is providing instructions to a client with a diagnosis of hypertension
regarding high- sodium items to be avoided. The nurse instructs the client to avoid
consuming which item?
Antacids
The nurse is preparing discharge instructions for a client with Raynaud's disease. The
nurse should plan to provide which instruction to the client?
Stop smoking because it causes cutaneous blood vessel spasm
The nurse is developing a plan of care for a client with varicose veins in whom skin
breakdown occurred over the varicosities as a result of secondary infection. Which is
a priority intervention? Elevate the legs higher than the heart
The nurse in the medical unit is reviewing the laboratory test results for a client
who has been transferred from the intensive care unit (ICU). The nurse notes that a
cardiac troponin T assay was performed while the client was in the ICU. The nurse
determines that this test was performed to assist in diagnosing which condition?
Myocardial infarction
The nurse is caring for a client with cardiac disease who has been placed on a
cardiac monitor. The nurse notes that the client has developed atrial fibrillation and
has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the
client for which finding?
Hypotension
The nurse is performing an assessment on a client with a diagnosis of left-sided heart
failure. Which assessment component would elicit specific information regarding the
client's left-sided heart function?
Listening to lung sounds
The nurse is participating in a class on rhythm strip interpretation. Which statement
by the nurse indicates an understanding of a PR interval of 0.20?
"This is a normal finding."
The nurse in the medical unit is assigned to provide discharge teaching to a client
with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that
, NCLEX Exam 2 Study Guide graded A
are needed to minimize the effects of the disease process. The client continually
changes the subject during
NCLEX Exam 2
Cardiac
A client admitted to the hospital with chest pain and a history of type 2 diabetes
mellitus is scheduled for cardiac catheterization. Which medication would need to be
withheld for 24 hours before the procedure and for 48 hours after the procedure?
Metformin
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20
mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous
fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results
indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum
creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the
nurse would anticipate that the client is at risk for which problem?
Acute Kidney Injury
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS
complexes are regular. The PR interval is 0.16 seconds, and QRS complexes
measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action
should the nurse take?
Continue to monitor
A client is wearing a continuous cardiac monitor, which begins to sound its
alarm. The nurse sees no electrocardiographic complexes on the screen. Which
is the priority nursing action? Check the client's status and lead placement.
The nurse is evaluating a client's response to cardioversion. Which assessment
would be the priority?
Status of airway
The nurse is caring for a client who has just had implantation of an
automatic internal cardioverter-defibrillator. The nurse should assess
which item based on priority?
Activation status of the device, heart rate cutoff, and number of shocks it is programmed
to deliver
A client's electrocardiogram strip shows atrial and ventricular rates of 110
beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08
seconds, and the PP and RR intervals are regular. How should the nurse correctly
interpret this rhythm?
Sinus tachycardia
The nurse is assessing the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. How should the nurse correctly interpret
the client's neurovascular status?
The neurovascular status is normal because of increased blood flow through the leg.
, NCLEX Exam 2 Study Guide graded A
The nurse is evaluating the condition of a client after pericardiocentesis
performed to treat cardiac tamponade. Which observation would indicate that
the procedure was effective? A rise in blood pressure
, NCLEX Exam 2 Study Guide graded A
A client with variant angina is scheduled to receive an oral calcium channel blocker
twice daily. Which statement by the client indicates the need for further teaching?
"My spouse told me that since I have developed this problem, we are going to stop
walking in the mall every morning."
The nurse is monitoring a client with acute pericarditis for signs of cardiac
tamponade. Which assessment finding indicates the presence of this complication?
Muffled or distant heart sounds
The home care nurse is providing instructions to a client with an arterial ischemic leg
ulcer about home care management and self-care management. Which statement,
if made by the client, indicates a need for further instruction?
"I need to be sure that I elevate my leg above the level of my heart for at least an hour
every day."
The nurse is providing instructions to a client with a diagnosis of hypertension
regarding high- sodium items to be avoided. The nurse instructs the client to avoid
consuming which item?
Antacids
The nurse is preparing discharge instructions for a client with Raynaud's disease. The
nurse should plan to provide which instruction to the client?
Stop smoking because it causes cutaneous blood vessel spasm
The nurse is developing a plan of care for a client with varicose veins in whom skin
breakdown occurred over the varicosities as a result of secondary infection. Which is
a priority intervention? Elevate the legs higher than the heart
The nurse in the medical unit is reviewing the laboratory test results for a client
who has been transferred from the intensive care unit (ICU). The nurse notes that a
cardiac troponin T assay was performed while the client was in the ICU. The nurse
determines that this test was performed to assist in diagnosing which condition?
Myocardial infarction
The nurse is caring for a client with cardiac disease who has been placed on a
cardiac monitor. The nurse notes that the client has developed atrial fibrillation and
has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the
client for which finding?
Hypotension
The nurse is performing an assessment on a client with a diagnosis of left-sided heart
failure. Which assessment component would elicit specific information regarding the
client's left-sided heart function?
Listening to lung sounds
The nurse is participating in a class on rhythm strip interpretation. Which statement
by the nurse indicates an understanding of a PR interval of 0.20?
"This is a normal finding."
The nurse in the medical unit is assigned to provide discharge teaching to a client
with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that
, NCLEX Exam 2 Study Guide graded A
are needed to minimize the effects of the disease process. The client continually
changes the subject during
